Right now I’m chilling at a Tim Hortons in Gander, sipping on my third tea of the day. I drove a few hours so I can hang with sister, niece and mom – niece has a swim meet and so I’m going to hang out with them. Plus, it’s the weekend before my birthday so it’ll be nice to have some company.
Anyway, on to my second interesting case. This one was definitely a rare situation; I don’t think my preceptors had ever seen it before.
(There are no gross pictures here. Promise.)
A patient presented to the emergency department with a relatively sudden onset of severe abdominal pain. I was asked by my preceptor to get a history and physical, which proved to be a half-terrifying experience. I’m not yet quite used to taking histories from patients who are screaming and writhing in agony, but I dove in there and got it done to the best of my ability. Plus, it’s something I’m going to have to get good at if I want to work in the emergency department.
The details of the history aren’t important and I don’t need to share them with you, but basically the emerg doc and the ER staff were unsure whether the patient was crazy, sick, or – even worse – both. When I went in to talk to her, I didn’t get the impression that she was a nut job, but rather in a heck of a lot of pain. Granted, I’m a touch naive, but still. My gut was telling me that she was really sick.
The surgeon agreed with me, and the nature of the problem was such that the only way we could sort things out was to have a peek inside the patient’s belly.
We started off laparoscopically, hoping that the problem could be fixed with a simple unkinking of the patient’s bowels (they had gotten a bit kinked up, it seemed). No such luck. Whatever had happened, they were too tangled to fix laparoscopically, so we had to open ‘er on up.
Now, most people probably think, “Ew, bowels? Ick.” But man, when the surgeon pulled loops of small bowel out of the patient’s open abdomen, I was in awe. Watching the small bowels do their peristalsis thing with my own eyes was one of the most amazing things I’ve ever seen. Honestly. I just stood there and gingerly touched a part of the intestine with my (sterile-gloved) finger as it contracted, and I experienced it with this gratefulness and wonderment that I didn’t expect.
The human body is just so incredible, and I feel so lucky to be on the path to becoming a physician, where I get to spend the rest of my career learning and healing and experiencing the body in all its crazy awesomeness.
Anyway, I’ll stop being sappy and philosophizing and explain what was going on with this poor lady who was in so much pain. Once we pulled out the affected loops of bowel and saw what was going on, we all totally understood why she was having such a rough go of it in the emergency room.
What had happened to her bowels was, she had a polyp in her small bowel (which is rare enough as it is, let alone to see one in a young, healthy woman), and that had caused something called intussusception.
Now, I have a relatively fragile grasp on all these things myself, so bear with me while I try to explain. Peristalsis is is a series of contractions and relaxations in the gastrointestinal tract that propels your food and all that good stuff along so it reaches the end of the road (so to speak). Wikipedia has a good, simplified picture of it:
What happened to this patient was that the bowel tried to move her polyp along with its peristalsis, but that pesky polyp wasn’t going anywhere since it was stuck to the bowel wall. Since the polyp was of a significant size, as this peristalsis happened, the distal bowel (the part of the intestine that’s further along the tract, closer to the end) to get sucked into the proximal bowel (the part of the intestine that’s closer to the beginning of the GI tract). This is the intussusception part.
The distal bowel getting sucked into the proximal bowel (intussusception) is kind of like how parts of a telescope collapse into each other.
See how one part of the bowel (ileum) is kind of being sucked into the other part (colon)? That’s what happened. Not to the same parts of the intestine, but you get the drift.
The part of this lady’s bowel that was intussuscepted was all ischemic (lost its blood supply) and dead, which is super painful and bad news bears. I mean, if she’d been somewhere that didn’t have access to surgery – like somewhere in rural Africa or something, I don’t know – she definitely would’ve died from this relatively quickly.
We couldn’t retract the intussuscepted bowel out where it was supposed to be (usually intussusception resolves on its own and doesn’t even need an operation), so we had to resect (take out) all the affected bowel – it was only when we cut it open to have a look after the operation that we saw how dead it was.
I wish I could show you a picture of what her bowel looked like, but I don’t think it’s exactly ethical to be sharing pictures of people’s guts on the internet. So, you’re all spared.
It’s remarkable to me how well the patient did after the operation. She was in hospital for a couple of days, progressing back to a normal diet of solid food, and then she was sent home with pretty much no pain. Amazing.
So, that’s that. Last post there were two well-differentiated groups of readers: those who thought it was all gross and those who thought it was cool. I’m obviously in the cool camp. (And I’m just cool in general, too.) I hope that for you guys who enjoy this kind of stuff, it was a bit educational! Learning is fun.